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Received Date: March 15, 2012; Accepted Date: March 29, 2012; Published Date: March 31, 2012
Citation: Careyva B, Salzman B, Plumb E, Kern SB (2012) Patient Perceptions of a Diabetes Group Visit Experience. J Community Med Health Edu 2:135. doi:10.4172/jcmhe.1000135
Copyright: © 2012 Careyva B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Context: This study assesses patient experiences with a diabetes group visit program in terms of satisfaction and impact on diabetes self-management. Preliminary data have demonstrated that group visits are a useful model to improve chronic disease management, particularly diabetes. To date, however, there is scarce data regarding patients’ perceptions of these experiences.
Objective: To determine patients’ perceptions of their experiences with a diabetes group visit program as well as self-reported impact on diabetes management. Methods: The study involves a semi-structured interview administered over the phone to group visit attendants. Participation in the survey was voluntary, and the data was recorded without patient identifiers. Three experienced reviewers analyzed the results for emerging themes.
Results: Twenty-five patients were interviewed. Eighty-four percent of patients reported attending the group visit because they were referred by their primary care physician. Most of the patients surveyed (88%) had completed at least three out of four sessions involved in the group visit program. Most patients (92%) reported that the group visit program influenced health behaviors related to diabetes including eating habits, blood glucose monitoring, taking medications, and exercise. Ninety-two percent of patients stated that they obtained more information about how to manage their diabetes during the group visit program than they had during traditional visits with their primary care provider.
Conclusions: Group visits are an innovative and efficient tool for the dissemination of diabetes related self- management education and support. Patients were most likely to attend if encouraged to do so by their primary care provider and most found that attending the class changed disease related behaviors.
Diabetes; Group visits; Chronic disease management
Diabetes impacts the lives of millions of individuals in the United States and worldwide, resulting in significant morbidity and mortality and decreased quality of life. The numbers of those impacted by this illness continue to climb, with current prevalence exceeding 9% of adults over the age of 20, or approximately 20 million individuals . Unfortunately, diabetes care in country is suboptimal, with only 57% of patients having the recommended hemoglobin A1C of less than 7% in order to prevent end-organ complications . Diabetes is also associated with a tremendous economic burden, with costs that exceed 170 billion dollars for both direct medical care and indirect costs secondary to disability, work loss, and premature mortality .
A critical aspect of diabetes care involves self-management education and support. Studies have shown that self-management education is associated with improved health outcomes and quality of life, as well as decreased emergency room visits, hospitalizations, and reduced overall costs [4,5]. However, self-management education is often neglected in a traditional health care delivery model. Group visits have evolved as an innovative way to optimize diabetes management and to provide self-management support in a practice-based setting. Benefits of group visits include improved patient satisfaction, provider satisfaction, quality of care, quality of life, reduced health care utilization, reduced overall costs, and possibly improved health outcomes, healthy behaviors, self-efficacy, physical function, and depression [6-13].
Group visits allow efficiency in dissemination of health information, as well as an opportunity for patients to interact with others facing similar challenges. Providing education and support for diabetes related self-care activities such as glucometer use, meal planning, and foot care may be challenging for clinicians to adequately cover in one on one 15-minute patient visits, especially given the incidence of co morbid illnesses that need to be addressed. While group visits have been found to have an impact on key diabetes measures and cost control, there is scarce qualitative data detailing the patient perception of these experiences. There is also tremendous heterogeneity between group visit models and little is known about what components render them effective or contribute to patient satisfaction .
DISH (Diabetes Information and Support for your Health) is a diabetes group visit program that started in July 2009 in a large, urban, academic Family Medicine practice. The group visit program meets on a weekly basis and consists of a rotating four-week cycle of interactive, patient-centered educational classes combined with medical care. Patients have private and personal time with a physician to assess their overall diabetes management with a focus on self-management support and creating a personal action plan. Physicians meet briefly with patients to optimize their glycemic, blood pressure, and lipid control. A chart review is performed to monitor and enhance the use of appropriate medications consistent with diabetes standards of care (i.e. ACE inhibitors, statins, aspirin), visits to ophthalmology and podiatry, and immunizations (influenza and pneumococcal vaccines). The one on one meeting with a physician is followed by a one-hour interactive educational session facilitated by one or more members of the diabetes health care team including a certified diabetes health educator, clinical pharmacist, mental health professional, occupational therapist, or physician. In addition, there is participation by medical students, pharmacy students, and medical assistants. The cycle of 4 weekly sessions addresses the following topics: an overview of diabetes, nutrition and healthy eating, reducing the risks and complications associated with diabetes, and other topics like medications or coping with diabetes. While the core topics are covered each month, patients may continue to attend sessions after completion of their initial fourweek cycle.
In a recent study, the DISH program demonstrated improvements in key diabetes outcome measures, including hemoglobin A1C, lipids, and blood pressure control . This program was developed and embedded in our practice as part of the mission to build a patient centered medical home. A HRSA residency-training grant provided support to develop the DISH program as a training model in chronic disease management for residents in Family Medicine. Additionally, the group visit program developed with support from the practice’s participation in the Southeastern Pennsylvania Chronic Care Initiative.
In this study, a semi-formatted telephone interview was conducted with DISH attendants to collect qualitative data about patients’ experience and satisfaction with the program in order to understand whether and how DISH affected diabetes related health behaviors.
Sample and Setting
A database was generated of all patients who attended the diabetes group visit program from July 2009 to August of 2010. Participants were included based on the following criteria: age 18 or older, a patient in the Jefferson Family Medicine Associates practices, and documented attendance of at least one diabetes group visit class. Patients who did not wish to participate in a phone survey were excluded. IRB approval was granted for this study and informed consent was obtained verbally for each participant.
The DISH diabetes registry, consisting of 199 participants, was randomized. Patients were contacted via telephone in the order of the randomization to achieve the goal of interviewing 25 patients. Patients were asked if they would like to participate in a survey about DISH. They were told that the study was voluntary and anonymous. The survey consisted of 18 semi-formatted questions. The questions were designed to gather data describing patients’ experiences and perceptions of DISH, impact of DISH on their diabetes self-management, as well as others logistical factors about scheduling and cost for internal purposes. Answers were transcribed by hand during the telephone interviews, and then, all responses were typed into a word document. The responses were numerically coded and did not contain any patient identifiers.
The survey transcriptions were compiled and evaluated by three individuals with qualitative research experience. Using standard phenomenological methods, described by Creswell, the investigators independently read the transcripts and made notations to identify preliminary thematic categories and to develop coding language that described the same phenomena . These themes were refined through several meetings until a consensus was reached regarding the most dominant themes that emerged from the groups. Once themes were established, the three reviewers independently categorized responses into the identified themes. The reviewers compared and discussed assigned themes until consensus was again achieved.
Twenty-five patients participated in an interview. Of the respondents, eighty-four percent of patients chose to attend group visits because their primary care physician referred them. The remainder of patients came to the group visit program because they saw an advertisement in the lobby or heard about the program from other patients in the practice.
Patients were asked to cite how many individual sessions they had attended, which were categorized as either 1-2, 3-5, or >5 sessions. The program is comprised of four sessions, one per week, but patients are invited to return as many times as they would like. It was found that 88% attended three or more sessions (Figure 1).
Impact on management of diabetes: In response to the question, “Do you think it [DISH] has changed the way you manage your diabetes?” ninety-two percent of participants responded, “yes.” The remaining participants reported “no” because they already had knowledge of the discussed topics. Of the 92% of those reporting that DISH impacted their diabetes self-management, patients specifically discussed positive changes in eating habits, exercise/physical activity, blood glucose monitoring, medications, and increased awareness/ mindfulness as the primary ways in which attending the group visits changed their disease management. In the words of some participants:
“I didn’t know how to check my blood sugar. I use my glucometer now. I like it.”
“It was really informative for me. I met so many people and developed a good relationship with everyone. I learned how to eat healthy to save my life. I took a group picture and gave it to everyone. I work long hours, and I would come home and make a big sandwich, have a bottle of soda, and go to bed. I realized I can’t do that. I was not a fish person. I am now learning to enjoy it. Also, eating in portions, which is the most important part. I cut back.”
“I now have a meter I use every day. I am very aware of what I eat. I do exercise. I now go to a gym for free with my insurance.”
“I am now able to give feedback to the people in the class when they say that they don’t think they can change. I did. I watch what I buy. If I don’t buy it, I don’t have to worry about eating it. We take it for granted that people do not know these things. I learned I must stay on my medications. I was able to bring my cholesterol down too.”
“I changed my eating habits. I learned to measure out foods and got calorie counting papers.”
“I stopped drinking. I used to have at least 4 a day. I am back on my medications faithfully. I had a wake up call when I went to get my tubes tied. They said my sugar was really high and couldn’t believe I couldn’t feel it.”
“I think it helped me be more aware of the fact that I wasn’t the only one with diabetes. It was okay to be aware of diabetes and to be keeping track of it all the time. Before that I had tried to ignore it as much as I could.”
“I didn’t know what diabetes was. My family called it sugar. I learned that eating healthy makes for a better life.”
Most difficult component of chronic disease management: When asked, “What is most difficult about taking care of your diabetes?” forty-eight percent of participants named changing eating habits as the most challenging component of their self-management. Other participants also mentioned difficulties associated with glucometer use and medication adherence. Some patients also noted that major challenges involved staying focused on managing their diabetes. Some specific patient responses include:
“Eating. You can’t hardly eat anything”.
“Staying focused. I need to be involved in something that keeps me on the straight and narrow”.
“Diet part. I was a junky. I just got bad eating habits.”
“I think the size of Metformin and other pills. I get tired of taking the medications. I get frustrated.”
“Learning how to eat all over again.”
“Accu-checks. Getting in the habit of doing them and writing down the numbers.”
It was noted during the analysis of these themes that the predominant themes for impact on diabetes management were similar to the themes named for the most challenging aspects of diabetes care. Figure 2 compares the percentage of respondents who mentioned these themes for the two different questions.
Impact of peers: Participants were asked, “How has talking to people in the class changed the way you think about diabetes?” Nearly half of responses (48%) indicated that interactions between the participants in the class had a large impact on the overall experience. Twenty-eight percent of participants noted the positive impact of peer support and an additional twenty percent mentioned that meeting others with diabetes alerted them to potential complications.
Several patients noted:
“Going to the class showed me how serious it is. I had no idea. People can go blind from this.”
“It makes a difference to hear the information from people who have diabetes.”
“I heard stories of some of the older patients. I didn’t want those things to happen to me. It made me start rethinking them.”
“It opens up your perspective, because everyone has a different story, but everyone’s story is similar. It makes you feel less alone.”
Most helpful about the class: In response to the question, “What did you find most helpful about the class?” the most frequent response (36%) involved nutritional counseling. Specific aspects of nutritional counseling that participants mentioned included learning about portions, carbohydrates, and reading food labels. The second most common response to what was most helpful about the class entailed peer support or the support from others in the class (16%). Some participants named learning about complications (12%) and exercise (8%) as what they found to be most helpful. Additional responses concerned improving self-management skills such as medication adherence (4%), glucometer use (8%), and diabetic foot care (4%).
In the words of several participants:
“Learning about labels. I still look at things when I buy them. It is on my mind every day now. Now I have to work on quantity.”
“What to eat and what type of exercise to do.”
“Talking to one another and listening to the speaker.”
“Sharing our stories of how we are eating.”
“Learning how to change your diet. That helps with diabetes and other ailments. Losing weight helped my sleep apnea.”
“I learned to take medicine to control the diabetes.”
Primary source of diabetes information: Participants were asked, “Did you learn more [at DISH] than while seeing your doctor at an appointment?” Ninety-two percent of participants answered, “yes” to this question. They noted that they needed the time and opportunities to ask questions in order to obtain the information to appropriately care for their illness. They also noted that the level of detail of information from the instructors exceeded what they had been previously given.
Like best: When asked, “What did you like best about DISH?” forty percent of participants noted the opportunities to learn skills to help them manage their diabetes on a day-to-day basis. Twenty-eight percent of patients noted that learning from others with diabetes was their favorite component of the group visits. Lastly, twelve percent described appreciation of the ability to ask questions and to have others listen to them. Some responses include:
“I liked being around other people with diabetes and learning how they handled their diabetes.”
“Freedom to talk. They listen to what you have to say.”
“It helped me learn what I needed to know to take care of this condition.”
Like least: In response to, “What did you like least about DISH?” sixty-eight percent of participants stated that there was nothing that they did not like about the program. The remaining participants stated cost of copays, time (would have preferred later in the day), and length of class (too short) as the components that they liked least.
While it has been well established that diabetes group visits are an effective tool to provide patient education and self-management support, the motivation to attend group visits has not been fully elucidated. In our study, we found that the vast majority of patients reported that they attended group visits because they were referred by their primary care provider. This result emphasizes the role of the physician in encouraging patients to participate in group visits to augment their current care.
Physicians may feel frustration with the difficulty of providing selfmanagement education and support within the time limits of an office visit . Diabetes group visits allow for engaging discussions about diabetes management and teaching outside of the time constraints of an office visit. The group visit program was designed to supplement but not supersede care provided by primary care providers. Progress notes are sent to patients’ primary care providers via the EMR (electronic medical record) to communicate when a patient attended a group visit and what transpired during the session. Of the 92% of patients who stated that they learned more about diabetes from the group visits than from their primary care physicians, many patients attributed learning more to having more time. When asked what they liked best about the group visit experience, many participants noted the ability to freely ask questions and feel that they were listened to, which also corresponds with the longer time period and open format afforded by group visits.
It has been noted from the Diabetes Control and Complications Trial that most patients are able to maintain behavior changes and improve diabetes control when given appropriate support and educational opportunities . Ninety-two percent of participants stated that their group visit experience had a positive impact on diabetes selfmanagement. Of those participants, ninety-two percent noted that the greatest changes in their diabetes related behaviors involved improving their eating habits, glucometer use, and medication adherence. Of interest, the behaviors that patients most frequently reported changing as a result of the group visit program corresponded to the aspects of diabetes that patients reported as being the most difficult to manage. We feel this demonstrates that the group visit curriculum addressed high priority topics for patients with diabetes, and as a result, patients were engaged and changed their behaviors.
The theme of nutrition, diet or healthy eating was the most common response to emerge regarding the impact of the group visit program on diabetes related health behaviors as well as the most challenging aspect of diabetes self-management. Clearly, food is a high priority topic for patients with diabetes and needs to be a core part of any group visit curriculum. Further, evidence shows that nutritional therapy is correlated with improved glycemic control . In the DISH program, the diabetes health educator spends a large percentage of time discussing the plate method, meal planning, healthy food choices, carbohydrate counting, and reading labels. Still, some patients reported that they would like even more education and support regarding nutrition. As dietary counseling is time consuming and often requires frequent repetition, the group visit is the ideal setting to discuss key strategies and problem-solve about making healthy food choices. While individualized diabetes nutritional plans are recommended, the group visit model allows for mass dissemination of core principles of diabetes appropriate nutritional recommendations .
The impact of peer support also played a large role in the group visit experience. Participants shared everything from stories about personal life struggles to recipes. Patients reported feeling less alone regarding their diabetes and felt supported by knowing that others were experiencing similar challenges. Hearing from different individuals with diabetes allowed participants to increase self-awareness about the impact of diabetes and complications they want to avoid. Several participants noted that they had not been aware of the seriousness of potential complications prior to attending DISH. As a result of this, some participants noted increased vigilance in disease self-management in order to avoid these potential complications. In addition to hearing from peers with diabetes, participants shared that they appreciated feeling listened to at the group visit. These poignant experiences cannot be replicated in a one on one office visit with a physician and seem to have a significant role in the value of the group visit experience. While other models of health promotion education, including social support groups, regular phone calls, and family participation, have been shown to have some benefit, diabetes group visits have demonstrated more consistent improvements in health behaviors and knowledge of diabetes [11,20].
Limitations to this study include the small sample size and the evaluation of group visits at only one practice. However, while the sample size was small, responses reached saturation, indicating that the sample size was representative of the group. In addition, there may have been selection bias as most of the patients interviewed reporting attending at least 3 group visit sessions. For a variety of reasons, patients who were more easily reached via phone to complete the interviews may have also attended more sessions than the average DISH participant. It is possible that we may have had more recent and reliable phone numbers for those who were attending more appointments in our office. It may also be that those who had positive experiences with the class were more likely to agree to participate in the survey.
These findings demonstrate that patients enjoyed diabetes group visits and found them helpful for learning skills to manage their diabetes. In addition, this study found that participation in a diabetes group visit program impacted health behaviors. These results are encouraging for further development of the group visit model for patients with diabetes and other chronic diseases. Further studies are needed to determine if self-reported changes in behavior correlate with actual behavior, result in improved health outcomes, and are sustainable overtime.
DISH (Diabetes Information and Support for your Health) is an innovative and efficient tool for the dissemination of diabetes related self-management education and support. Patients were most likely to attend if recommended to do so by their primary care provider and most found that attending the program changed disease related behaviors, including dietary modifications, increased blood glucose monitoring, adherence to medications, and implementing exercise. A majority of participants noted the benefit of peer interaction and support.
Dr. Salzman and Dr. Kern received partial support for this project from the following HRSA residency training grant: HRSA Residency Training in Primary Care, D58HP05138. The authors wish to thank Dr. Patrick McManus, Dr. Victor Diaz, and Dr. Neva White for their devotion and commitment to the DISH group visits in addition to our patients for sharing their time and thoughts.
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